Moderate Doses Of Steroids Research Articles

Quality of Care for Patients With Systemic Lupus Erythematosus: Data From the American College of Rheumatology RISE Registry.

Although multiple national quality measures focus on the management and safety of rheumatoid arthritis, few measures address the care of patients with systemic lupus erythematosus (SLE). Our objective was to apply a group of quality measures relevant to the care of patients with SLE, and we used the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry to assess nationwide variations in care. The data derived from RISE and included patients who had ≥2 visits with SLE codes ≥30 days apart in 2017-2018. We calculated performance on 5 quality measures: renal disease screening, blood pressure assessment and management, hydroxychloroquine (HCQ) prescribing, safe dosing for HCQ, and prolonged glucocorticoid use at doses of >7.5 mg/day. We reported performance on these measures at the practice level. We used logistic regression to assess independent predictors of performance after adjusting for sociodemographic and utilization factors. We included 27,567 unique patients from 186 practices; 91.7% were female and 48% White, with a mean age of 53.5 ± 15.2 years. Few patients had adequate screening for the development of renal manifestations (39.5%). Although blood pressure assessment was common (94.4%), a meaningful fraction of patients had untreated hypertension (17.7%). Many received HCQ (71.5%), but only 62% at doses of ≤5.0 mg/kg/day. Some received at least moderate-dose steroids for ≥90 days (18.5%). We observed significant practice variation on every measure. We found potential gaps in care for patients with SLE across the US. Although some performance variation may be explained by differences in disease severity, dramatic differences suggest that developing quality measures to address important health care processes in SLE may improve care.

Should PLEX Be Used for Severe AKI and/or Pulmonary Hemorrhage in ANCA-Associated Vasculitis (AAV)? CON.

Vasculitis associated with the formation of ANCA manifests in several forms defined by the extent of organ involvement (renal limited or systemic), with or without granulomatous tissue involvement, and by the presence and nature of the ANCA (antimyeloperoxidase or antiproteinase 3 and associated autoantibodies, in particular antiglomerular basement membrane [anti-GBM] autoantibodies) (1). Severe kidney disease with extensive crescentic involvement and a clinical syndrome of rapidly progressive GN is common in all forms of ANCA-associated vasculitis (AAV) (1). Diffuse alveolar hemorrhage (DAH), of varying severity, can be seen in many kinds of GN (Goodpasture syndrome) but is particularly common in AAV, with or without anti-GBM antibody (2). The therapy of AAV has greatly improved in recent years, and the use of rituximab (RTX), cyclophosphamide (CYC), or combinations of RTX and CYC plus moderate doses of steroids can effectively and safely induce a complete or partial remission in the great majority of patients (3 ⇓–5). The role of adjunctive therapy with plasmapheresis (PLEX) has been controversial, except in cases where anti-GBM autoantibody disease is found alone or concomitantly with AAV. The publication of the large Plasma Exchange and glucocorticoid dosing in treatment of anti-neutrophil cytoplasmic antibody associated vasculitis (PEXIVAS) trial in 2020 has generated much attention to this controversy (6). This debate focuses on this controversy by laying out a precise question: should PLEX be used for severe AKI and/or pulmonary hemorrhage in patients with AAV? For this debate, I will interpret “severe” as meaning the need for artificial organ support (dialysis for AKI or mechanical ventilation for DAH). I will also interpret ANCA vasculitis as meaning a positive (antimyeloperoxidase or antiproteinase 3 autoantibody in the absence of anti-GBM antibody and clinical or morphologic evidence of a vasculitis involving the kidney without or with extrarenal involvement, including DAH. …

Clinical Outcomes of Myocarditis after Moderate-Dose Steroid Therapy in Systemic Sclerosis: A Pilot Study.

Background Myocarditis is reported in systemic sclerosis (SSc); however, treatment options and outcomes are limited. Our objective was to define cardiac outcomes after moderate-dose steroid therapy in SSc patients with myocarditis. Method An open-label study was conducted among SSc patients with myocarditis—as defined by cardiovascular magnetic resonance (CMR), disease onset <5 years, and a NYHA functional class ≥II. All enrolled patients received prednisolone (30 mg/d) which would be tapered off by week 24, and CMR was followed up at the end of treatment. Results A total of 20 SSc patients were enrolled which 12 patients completed the study. At week 24, 8 of the 12 cases experienced improvement of myocarditis. Compared to those with no improvement, these 8 patients had significantly longer disease duration (p = 0.03), higher heart rate at baseline (p = 0.049) and week 24 (p = 0.04), lower left ventricular (LV) and right ventricular (RV) stroke volume at baseline (p = 0.002 and p = 0.01) and week 24 (p = 0.01 and p = 0.02), and lower LV and RV cardiac output at week 24 (p = 0.01 and p = 0.01). Four cases died during follow-up (3 due to cardiac complications, 1 due to renal crisis). The two who died from heart failure had very high NT-prohormone-brain natriuretic peptide (NT-proBNP) and impaired LV ejection fraction (LVEF), and the one who died from arrhythmia had very high sensitivity of cardiac Troponin-T (hs-cTnT). Conclusions Moderate-dose steroid therapy may improve myocarditis in SSc. A proportion of patients died due to cardiac complications during treatment, particularly those with high hs-cTnT, high NT-proBNP, and impaired LVEF. This trial is registered with NCT03607071.

Comparison of the efficacy of various doses of steroids for acute facial palsy

Background: Although steroids are effective for multiple types of acute facial palsies, an appropriate dosage remains to be established.Aims/Objectives: The objective of this study is to compare the efficacy of high, low, and moderate doses of steroids in patients with acute facial palsy.Materials and methods: We retrospectively reviewed the medical records of 49 patients with Bell palsy, Ramsay Hunt syndrome, or traumatic facial palsy. The patients were divided into 3 groups. We determined the initial House-Brackmann (HB) grade of each patient and the HB grade at the 3-month follow-up to determine whether complete recovery was achieved.Results: Results of electroneurography showed that the average and maximum rates of degeneration were not statistically different among the groups. Although the HB grade showed improvement after 3 months, the initial score was not significantly different from that at the follow-up. The degree of recovery was not significantly different among the groups.Conclusion and significance: Our findings showed that a high dose of steroids did not achieve outcomes that were more clinically meaningful than did that of a moderate or a low-dose steroid. Therefore, moderate or low doses of steroids may be sufficient for the treatment of acute facial palsy.

Granulomatosis with Polyangiitis Presenting as Postoperative Gastrointestinal Stromal Tumors: A Case Report

Introduction: Granulomatosis with polyangiitis (GPA) is a systemic vasculitis syndrome, previously known as Wegener’s granulomatosis, characterized by necrotizing granulomatous inflammation of the respiratory tracts, systemic necrotizing vasculitis, and necrotizing glomerulonephritis. This disorder represents a significant diagnostic dilemma due its diverse presentations, although presentation in the form of postoperative gastrointestinal stromal tumors is uncommon. Here, we report one of the first identified cases of GPA presenting as postoperative gastrointestinal stromal tumors (GISTs). Case presentation: A 78-year-old Chinese man presented to our Respiratory Department in Zhejiang Hospital of Traditional Chinese Medicine with a history of progressively worsening fever and pulmonary nodules. He had history of postoperative gastrointestinal stromal tumors. Because of failed treatment with antibiotics, he had been diagnosed with a fungal infection of the lung, which was empirically treated with voriconazole for approximately two months. However, the condition did not improve until the patient was successfully treated with moderate-dose steroids. His clinical course was fever, pulmonary nodules and nasosinusitis, which are associated with granulomatosis with polyangiitis. Conclusion: The recognition of a multisystem disease is critical for diagnosing GPA. Postoperative GISTs may be associated with manifestations of the disease, in which case, immediate and aggressive treatment with steroids can be life-saving.

The Role of Corticosteroids in Adult Respiratory Distress Syndrome caused by Viridans Group Streptococci Bacteremia in Neutropenic Patients.

In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bacteremia in neutropenic patients with cancer. The clinical course of VGS bacteremia can be devastating including septic shock and adult respiratory distress syndrome (ARDS). It has been suggested that septicemia with VGS triggers the development of noncardiogenic pulmonary edema in patients with pre-existing damage of the lungs due to aggressive cytotoxic treatment. Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.

High-dose steroid therapy for idiopathic optic perineuritis: a case series

IntroductionIt has been reported that the prognosis of optic perineuritis may be poor when initiation of treatment is delayed. Here we report the successful treatment of three patients with idiopathic optic perineuritis, including two in whom initiation of therapy was delayed.Case presentationThree Japanese patients (two women aged 73 and 66 years, and one man aged 27 years) presented with loss of vision (for five months, several months, and two months respectively) and pain on eye movement in the third case only, and were diagnosed as having idiopathic optic perineuritis. Fat-suppressed T2-weighted magnetic resonance images showed high signal intensity areas around the affected optic nerves, suggesting the presence of optic perineuritis. Two patients received steroid pulse therapy and the third was given high-dose steroid therapy. The visual acuity improved in all three cases.ConclusionHigh-dose steroid therapy may be effective for idiopathic perineuritis in patients without optic nerve atrophy, even if initial treatment (including moderate-dose steroids) has failed.

Clinical characterization and successful treatment of 6 patients with Churg–Strauss syndrome-associated neuropathy

Objective To confirm the reported findings and clarify unknown clinical features of Churg–Strauss syndrome (CSS)-associated neuropathy and design appropriate treatment. Patients and methods We assessed the clinical features of 6 patients with CSS-associated neuropathy. Results Mononeuritis multiplex was present in 4 cases and polyneuropathy in the remaining cases. Both groups progressed to sensori-motor polyneuropathy in an acute or subacute course. All cases showed bronchial asthma and eosinophilia. Two cases with serum antineutrophil cytoplasmic antibodies to myeloperoxidase (MPO-ANCA) had an acute clinical course and severe symptoms. Nerve conduction studies (NCS) of these 2 cases revealed conduction blocks at the initial stage, although NCS finally indicated sensori-motor axonopathy at the involved extremities. For treatment, high-dose corticosteroid therapy for 4 cases, and cyclophosphamide combined with corticosteroids for 1 case, were effective. For the remaining case, intravenous immunoglobulin (IVIg) at the chronic phase resulted in a slow improvement of neuropathy in the symptomatic aspect. There was no relapse of neuropathy with low-dose corticosteroid treatment for 14–24 months after the initial treatment, except 1 case. There was also no relapse in the other case that was treated with moderate-dose steroids. Conclusion Our study showed that CSS-associated neuropathy is a treatable disorder and that the first choice therapy is high-dose corticosteroid. In cases where corticosteroids are ineffective or for severe cases, immunosuppressive therapy (cyclophosphamide) with steroids should be considered, and IVIg might be a treatment option.

Predominant tubulointerstitial nephritis in a patient with systemic lupus erythematosus: phenotype of infiltrating cells

A 63-year-old man with systemic lupus erythematosus developed tubular proteinuria. All subclasses of serum IgG increased, and the largest IgG subclass increase was IgG4. A renal biopsy showed lupus nephritis (Class II) with severe tubulointerstitial nephritis (so-called predominant tubulointerstitial lupus nephritis, an unusual form of lupus nephritis). Immunofluorescence microscopy revealed positive granular staining for IgG, C3 and C1q in the mesangium and peritubular interstitium, and along the tubular basement membranes (TBM). Electron microscopy also showed electron-dense deposits in the mesangium and TBM. Immunophenotyping of interstitial infiltrating cells disclosed a predominance of T cells. CD8-positive cytotoxic T cells infiltrated the peritubular interstitium, and some of these cells infiltrated the tubules. B cell-rich lymphoid follicles were also observed. IgG subclass analyses showed glomerular IgG1, IgG2 and IgG4 deposition, positive staining of IgG4 in the peritubular interstitium and along the TBM, and abundant IgG1-, IgG3- and IgG4-positive plasma cells in the interstitium. The patient responded well to moderate-dose steroid therapy. This is the first report of immunophenotyping of interstitial infiltrates in predominant tubulointerstitial lupus nephritis. The results suggest CD8-positive cytotoxic T cell-mediated tubular injury. Furthermore, immune complexes containing IgG4 might be one of etiologic factors.

Steroidal and Nonsteroidal Antiinflammatory Medications Can Improve Photoreceptor Survival after Laser Retinal Photocoagulation

To determine whether methylprednisolone or indomethacin can enhance photoreceptor survival after laser retinal injury in an animal model. Experimental study. Twenty rhesus monkeys. Twenty rhesus monkeys (Macaca mulatta) received a grid of argon green (514.5 nm, 10 ms) laser lesions in the macula of the right eye and a grid of neodymium:yttrium-aluminum-garnet (Nd:YAG; 1064 nm, 10 ns) lesions in the macula of the left eye, followed by randomization to 2 weeks of treatment in 1 of 4 treatment groups: high-dose methylprednisolone, moderate-dose methylprednisolone, indomethacin, or control. The lesions were assessed at day 1, day 14, 2 months, and 4 months. The authors were masked to the treatment group. This report discusses the histologic results of ocular tissue harvested at 4 months. The number of surviving photoreceptor cell nuclei within each lesion was compared with the number of photoreceptor nuclei in surrounding unaffected retina. The proportion of surviving photoreceptor nuclei was compared between each treatment group. Argon retinal lesions in the high-dose steroid treatment group and the indomethacin treatment group demonstrated improved photoreceptor survival compared with the control group (P = 0.004). Hemorrhagic Nd:YAG lesions demonstrated improved survivability with indomethacin treatment compared with controls (P = 0.003). In nonhemorrhagic Nd:YAG laser retinal lesions, the lesions treated with moderate-dose steroids demonstrated improved photoreceptor survival compared with the control group (P = 0.004). Based on histologic samples of retinal laser lesions 4 months after injury, treatment with indomethacin resulted in improved photoreceptor survival in argon laser lesions and hemorrhagic Nd:YAG laser lesions. Treatment with systemic methylprednisolone demonstrated improved photoreceptor survival in argon retinal lesions and in nonhemorrhagic Nd:YAG lesions.

Glomérulonéphrite extra-membraneuse au cours d’un syndrome de Gougerot-Sjögren primitif

Glomerulonephritis, mainly membranoproliferative or membranous (MG), is observed much less often than interstitial involvement in Sjögren's syndrome (SS).We report a case of MG revealed by thrombosis of the inferior vena cava and of a renal vein in a 40-year-old woman with primary SS, which began with polyarthritis, immune-type lymphadenopathy, and Hashimoto thyroiditis and did not include obvious sicca syndrome. After failure of moderate-dose steroids and then azathioprine, each over separate 9-month periods, the MG responded well within a few weeks to monthly alternation of methylprednisolone and oral cyclophosphamide for 6 months.SS may be an underestimated cause of glomerulonephritis, especially membranoproliferative and membranous glomerulonephritis. They should be considered even in the absence of obvious sicca syndrome. Although the prognosis is usually good, renal insufficiency can occur. In cases of MG, if moderate-dose steroids fail, monthly alternation of methylprednisolone and cyclophosphamide for 6 months appears effective and well tolerated, with a low risk of carcinogenicity.

Intravascular lymphoma associated with systemic lupus erythematosus

AbstractWe report a case of systemic lupus erythematosus (SLE) associated with intravascular (angiotropic) lymphoma. A 27‐year‐old woman had been suffering from uncontrolled severe eruptions for a long time and was admitted because of high fever due to hemophagocytic syndrome (HPS). As her SLE had not been well‐controlled by moderate doses of steroids and azathioprine, autoimmune associated HPS was first considered. She was initially treated with steroid pulses and γ‐globulin for HPS. However, chromosomal analysis of bone marrow cells revealed severe abnormalities. After malignant lymphoma‐associated HPS was diagnosed, chemotherapy was commenced in the intensive care unit with artificial respiration and continuous hemodiafiltration. The patient died of cerebral infarction at day 45. It is suggested that the SLE itself was associated with the development of the intravascular lymphoma rather than due to the azathioprine.

Infection in critically ill patients: clinical impact and management.

The aim of this review is to summarize recent developments in the epidemiology, diagnosis and management of infection in critically ill patients. New definitions of sepsis, including a grading system, similar to the tumor, node, metastasis system for cancer, have been suggested and are being developed. In terms of epidemiology, sepsis remains an important cause of morbidity and mortality among the critically ill, but the last couple of years have seen the development and licensing of a new immunomodulatory agent, drotrecogin-alpha (activated) that reduces mortality. Moderate doses of steroids have also been shown to improve outcomes for patients with septic shock. Improved characterization of septic patients will help target and monitor new therapies. Newly developed immunomodulatory strategies and others currently undergoing clinical testing will help reduce the high mortality rates seen in this disease

Severe aplastic anemia and allogeneic hematopoietic stem cell transplantation.

Aplastic anemia is a form of bone marrow failure that ranges in severity from mild to severe. In all cases, some degree of pancytopenia is present. The cause usually is unknown, although many drugs and viruses are associated with the disease. The pathophysiology of aplastic anemia involves either a stem cell defect or injury or an immunologically mediated hematopoietic cell destruction, which may operate in concert with abnormalities in programmed cell death. Excellent clinical care and research have dramatically improved patient survival, with 70% to 90% of sibling hematopoietic stem cell transplant recipients surviving long term. Patients with mild or moderate disease may not require immediate treatment. If and when these patients require treatment, the mainstay of therapy is immunosuppression. The initial drug regimen includes antithymocyte globulin, often in combination with cyclosporine A, followed by moderate-dose steroids and cyclophosphamide. Nurses assess and monitor patients and their progress, recognizing medication adverse effects. Nurses educate patients about their disease and its treatment, and provide necessary emotional support. Severe aplastic anemia is treated with allogeneic hematopoietic stem cell transplantation. This therapy involves complex nursing challenges. The patient goes through an extensive pretransplantation workup. Donor selection and harvesting of hematopoietic stem cells are preludes to an intensive preparative regimen. This preparative or conditioning regimen and the need for long-term immunosuppression are the reasons for many of the acute complications and adverse events that may follow the hematopoietic stem cell transplantation. Nurses must be vigilant in assessing and monitoring patients for toxicities and long-term complications that may affect almost any organ system.

Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline.

To review the literature for malignant extradural spinal cord compression (MSCC), produce evidence-based recommendations based on the criteria used by the Canadian Task Force on the Periodic Health Examination, and make suggestions regarding future research directives. A systematic review of the literature with explicit study selection and evaluation criteria was performed. Primary outcome measure was posttreatment ambulation rate. There is good evidence to support the use of high-dose dexamethasone (96 mg/d), but inconclusive evidence for the use of moderate-dose steroids (16 mg/d) in conjunction with radiotherapy (RT) for the treatment of MSCC. Fair evidence exists for not using steroids in patients who are nonparetic and ambulatory pretreatment, and to give radiation to patients with subclinical spinal cord compression (SCC). The remainder of the recommendations are based on inconclusive evidence: RT alone should be the first-line treatment for ambulatory patients except when there is spinal instability, bony compression, or paraplegia on presentation, in which case surgery should be performed. Either modality can be used for paraparetic patients who are nonambulatory. Postoperative RT should be considered for tumor in residua. Ambulatory, undiagnosed patients should have needle biopsy attempted first. Patients should be aggressively screened and educated about SCC. In general, there were very few papers of high methodologic quality found in the literature. More studies are needed to satisfy the validity of many of the clinical decisions that are made today with regard to the management of MSCC.

Eosinophilic temporal and systemic arteritis

We describe a 39-year-old patient with an unusual type of bilateral temporal arteritis characterized histologically by inflammation, diffuse eosinophilic infiltration, destruction of elastic tissue, and fibrosis. In addition, the patient had a history of systemic vasculitis, peripheral eosinophilia, eosinophilic lymphadenitis, and membranous glomerulonephritis. The patient has been followed up for 14 years and is well controlled on moderate doses of steroids. We propose that this patient suffers from an immune reaction to an unknown, possibly infectious, antigen.

PREVENTION OF REJECTION AND GRAFT LOSS WITH AN AGGRESSIVE QUADRUPLE IMMUNOSUPPRESSIVE THERAPY REGIMEN IN CHILDREN AND ADOLESCENTS

During the two-year period May 1991 to April 1993, 36 kidney transplants were performed in children less than 18 years of age at California Pacific Medical Center using an aggressive quadruple-therapy regimen of immunosuppression. The regimen consisted of induction with an antilymphocyte preparation (MALG in 21, OKT3 in 2, ATGAM in 12, none in 1), initial moderate-dose steroid therapy, early intravenous cyclosporine therapy, and azathioprine. Twenty living-related graft recipients were pretreated with donor-specific transfusions. Long-term cyclosporine was dosed by levels to keep through whole-blood levels (RIA) at 200-300 ng/ml. Twenty-five grafts were from living-related donors, two from living unrelated donors, and nine from cadaveric donors. Eleven (30%) recipients were five years old or under at the time of transplantation. Of these recipients 44% had complex congenital urologic disease and required urologic surgery prior to or at the time of transplantation. Patients have been followed for a mean of one year, with actual patient and graft survivals of 100% and 97%, respectively. Only one graft has been lost, to severe, early recurrent focal segmental glomerulosclerosis. Four of the 36 patients have had one rejection episode each, all reversed completely. Graft function is stable, with serum creatinine proportionate to age--mean serum creatinine in the children under two years old being 0.4 mg/dl, and in the adolescents 1.3 mg/dl, with two adolescent boys having the highest creatinine levels at 1.8 mg/dl. We conclude that an aggressive approach to immunosuppressive therapy in the early posttransplant period with MALG/OKT3/ATGAM induction and rapid achievement of therapeutic cyclosporine levels prevents rejection and results in excellent patient and graft survival with subsequent stable good graft function.

Hydrocortisone in chloramphenicol-treated severe typhoid fever in Papua New Guinea

We investigated the effect of hydrocortisone on mortality and complications in chloramphenicoltreated severe typhoid fever (STF) in Goroka, Papua New Guinea. Of 374 culture-positive patients, 146 formed a retrospective comparison group, of whom 41 had STF. Of 228 patients in the intervention group, 58 had STF. Patients without STF had low mortality (2·5%) with standard treatment. In the intervention group, hydrocortisone was used in two dosage schedules, 100 mg for 12 doses (23 patients) and 400 mg for 12 doses (23 patients). There was no difference in mortality between steroid-treated and comparison STF patients (44·8% versus 43·9%) or in complications, and we conclude that moderate doses of steroids are not beneficial in severe typhoid fever.

Renal transplantation between HL-A identical donor-recipient pairs. Functional and morphological evaluation.

16 patients underwent renal transplantation from a sibling donor who was prospectively determined to be ABO compatible and HL-A identical with the recipient. Unidirectional mixed leukocyte reactions were performed; in each instance, lymphocyte stimulation in either direction was not observed. The plasma creatinine 10-68 months after transplantation in these 16 patients ranged between 0.9 and 1.9 mg/100 ml. The creatinine clearance ranged from 48 to 113 ml/min, and the blood urea nitrogen (BUN) ranged between 12 and 35 mg/100 ml. Urine protein excretion varied from 0.11 to 1.86 g/day. Six patients exhibited no detectable clinical episodes of acute rejection; they were treated with azathioprine alone and each of them demonstrated normal or near normal renal histology when biopsy specimens were obtained more than 6 months after transplantation. Nine patients experienced acute rejection episodes that required the use of steroid therapy. The severity of these rejection episodes was variable; they included a mild reduction in renal function with an immediate steroid-induced restoration of function and eventual discontinuance of steroid therapy to severe reduction in function requiring prolonged and moderate doses of steroids without return to normal renal function. Renal histological observations in this group ranged from mild to marked cellular and structural changes which fit the criteria of the rejection. One patient demonstrated a gradual loss of renal function with heavy proteinuria. Biopsy of this allograft demonstrated the recurrence of original disease, i.e., lobular glomerulonephritis. The marked variability in the clinical course and allograft morphology in these 16 patients could be explained by antigenic differences at non-HL-A loci. The presence of minor histocompatibility loci has been well documented in other mammalian species and they are most certainly present in man. The need for their identification and definition is stressed.